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Health Systems Division Integrated Health Programs

Standards for Approval/Licensure

of Alcohol and Other Drug Abuse

Programs

Administrative Rulebook

Chapter 415, Division 12

Effective December 14, 2016

Table of Contents

415-012-0000 - Purpose and Scope ............................................................................... 1

415-012-0010 – Definitions ............................................................................................. 2

415-012-0020 –General Requirements ........................................................................... 4

415-012-0030 – Initial Application Procedures ................................................................ 5

415-012-0032 – Initial Application Information ................................................................ 6

415-012-0035 – Responses To Application .................................................................... 8

415-012-0040 – Licenses ................................................................................................ 9

415-012-0050 – Onsite Reviews and Access Requirements ........................................ 11

415-012-0055 –Review Process and Review Reports .................................................. 13

415-012-0057 – Organizational Provider Assessment Information ............................... 14

415-012-0058 – Availability of Information to Coordinated Care Organizations and Other Health Plans .................................................................................................................. 15

415-012-0060 – Denial, Revocation, or Non-renewal ................................................... 16

415-012-0065 – Suspension of License ........................................................................ 17

415-012-0067 – Response to Criminal Records ........................................................... 18

415-012-0070 – Hearings (T) ........................................................................................ 19

415-012-0080 – Complaints .......................................................................................... 20

415-012-0090 – Variance or Exception ......................................................................... 22

Standards for Approval/Licensure of Alcohol and Other Drug Abuse Programs

1 OAR 415-012-0000 (12/14/2016)

415-012-0000 - Purpose and Scope

Purpose. These rules establish procedures for the residential licensure of the following:

(1) Any substance use disorder service provider which is, or seeks to be, contractually affiliated with the Health Systems Division (HSD), a Coordinated Care Organization (CCO), or a local mental health authority for the purpose of providing residential alcohol and other drug abuse treatment and prevention services;

(2) Any service provider using public funds in the provision of residential substance use disorder prevention, intervention, or treatment services in Oregon;

(3) Performing providers under HSD rules OAR 410-172-0600 through 410-172-0860.

(4) Organizations seeking approval from the Division for provision of residential services as provided in ORS 430.010 and 443.400 or detoxification services under ORS 430.306; or

(5) Alcohol and drug evaluation specialists designated to do Driving Under the Influence of Intoxicants (DUII) diagnostic screenings and assessments under ORS 813.020 and 813.260.

(6) Scope. These rules do not establish procedures for regulating behavioral health care practitioners that are otherwise licensed to render behavioral healthcare services in accordance with applicable statutes. These rules do not establish procedures for regulating practices exclusively comprised of behavioral healthcare practitioners that are otherwise licensed to render behavioral healthcare services in accordance with applicable statutes. These rules do not establish procedures for regulating behavioral health treatment services.

Stat. Auth.: ORS 413.042 & 430.256 Stats. Implemented: ORS 430.010, 430.306, 430.397, 430.405, 430.450, 430.590, 430.630, 430.850, 443.400, 813.020, 813.260 & 813.500

December 14, 2016 Rulebook

OAR 415-012-0020 (12/14/2016) 2

415-012-0010 – Definitions

(1) "Applicant" means any person or entity who has requested, in writing, a license.

(2) "Chief Officer" means the Chief Health Systems Officer of the HSD, or his or her designee.

(3) "Community Mental Health Program (CMHP)" means the organization of all services for individuals with mental or emotional disturbances, drug use problems, mental retardation or other developmental disabilities, and alcoholism and alcohol use problems, operated by, or contractually affiliated with, a local mental health authority, operated in a specific geographic area of the state under an intergovernmental agreement or direct contract with the Division.

(4) “Coordinated Care Organization (CCO)” means an entity that has been certified by the Authority to provide coordinated and integrated health services.

(5) "Contract" is the document describing and limiting the relationship and respective obligations between an organization other than a county and the Division for the purposes of operating the alcohol and drug use disorder service within a county's boundaries, or operating a statewide, regional, or specialized service.

(6) “Division” means the Health Systems Division (HSD) of the Oregon Health Authority.

(7) “Individual” means the person requesting or receiving services addressed in these rules.

(8) "Intergovernmental Agreement" or "Agreement" is the document describing and limiting the contractual relationship and respective obligations between a county or other government organization and the Division for the purpose of operating an alcohol and drug use disorder service.

(9) "License" means a license issued by the Division to applicants who are in substantial compliance with applicable administrative rules for alcohol and drug use treatment in a residential setting and which is renewable every two years.

(10) “Licensed Child Care Facility” means a facility licensed under ORS 657A.280.

(11) "Non-Funded Provider" means an organization not contractually affiliated with the Division, a CMHP, or other contractor of the Division.

(12) "Provider" means an organization licensed under these rues whom is providing substance abuse prevention, intervention, or treatment services under contract with the Division or under subcontract with a local entity or public body or otherwise receiving public funds for these services.

(13) "Provisional" means a license issued for one year or less pending completion of specified requirements because of substantial failure to comply with applicable administrative rules.


3 OAR 415-012-0010 (12/14/2016)

(14) "Quality Assurance" means the process of objectively and systematically monitoring and evaluating the quality and appropriateness of care to identify and resolve identified problems.

(15) "Restriction" means any limitations placed on a license such as age of individuals to be served or number of individuals to be served.

(16 "Revocation" means the removal of authority for a provider to provide certain services under a license.

(17) “School Attended Primarily By Minors” means an existing public or private elementary, secondary or career school attended primarily by individuals under age eighteen.

(18) "Service Element" means a distinct service or group of services for persons with alcohol or other drug use disorders defined in administrative rule and included in a contract or agreement issued by the Division.

(19) "Substantial Compliance" means a level of adherence to applicable administrative rules which, while not meeting one or more of the requirements, does not, in the determination of the Division:

(a) Constitute a danger to the health or safety of any individual;

(b) Constitute a willful or ongoing violation of the rights of service recipients as set forth in administrative rules; or

(c) Prevent the accomplishment of the state's purposes in approving or supporting the subject service.

(20) "Substantial Failure to Comply" is used in this rule to mean the opposite of "substantial compliance."

(21) "Suspension" means a temporary removal of authority for a provider to conduct a service for a stated period of time or until the occurrence of a specified event under a LOA or license.

(22) "Temporary" means a LOA license issued for 185 days to a program approved for the first time. A temporary LOA license cannot be extended.

(23) "Variance or Exception" means a waiver of a regulation or provision of these rules granted by the Division upon written application.

Stat. Auth.: ORS 413.042 & 430.256 Stats. Implemented: ORS 430.010 - 430.030, 430.306, 430.397, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020, 813.260 & 813.500


OAR 415-012-0020 (12/14/2016) 4

415-012-0020 –General Requirements

(1) Providers That Must Have a License: Every provider that operates a residential service element by contract with the Division or subcontracts with a local entity or public body or otherwise receives public funds for providing substance abuse prevention, intervention, or treatment services must have a license:

(a) No provider shall represent themselves as conducting any service described in this rule without first obtaining a license;

(b) A provider that does not have a license for conducting a service described in this rule may not admit a person needing that service; and

(c) The license shall be posted in the facility and available for inspection at all times.

(2) Licensed providers must also maintain a current certificate of approval for the provision of behavioral health treatment services per OAR 309-008-0100 to 309-008-1600 if also providing an outpatient service.

(3) Facilities Requiring License: Any facility which meets the definition of a residential treatment facility for substance-dependent persons under ORS 443.400 or a detoxification center as defined in ORS 430.306 must be licensed by the Division:

(a) No individual or entity shall represent themselves as a residential treatment facility for substance-dependent persons or as a detoxification center without first being licensed;

(b) A residential treatment facility or a detoxification center that is not licensed may not admit individuals needing residential or detoxification care or treatment; and

(c) A license shall be posted in the facility and available for inspection at all times.

(4) License is not a Contract: Approval or licensure of a service element pursuant to this rule does not create an express or implied contract in the absence of a fully executed written contract.

(5) Distance Requirements for Methadone Treatment Programs: Programs using methadone to treat opioid addiction may not operate within 1,000 linear feet of a licensed child care facility or school primarily attended by minors pursuant to ORS 430.590. The Division will not issue a variance to programs unable to meet this requirement.

Stat. Auth.: ORS 430.256

Stats. Implemented: ORS 430.010-030, 430.306, 430.397, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020, 813.260 & 813.500


5 OAR 415-012-0030 (12/14/2016)

415-012-0030 – Initial Application Procedures

(1) Application Packet: The Division shall mail an application packet to all applicants seeking residential licensure under these rules.

(2) Initial Meeting: All programs applying for the first time for a residential license to operate a treatment or prevention program shall schedule a meeting with Division staff for the purpose of receiving needed technical assistance regarding the approval and licensure criteria and procedures.

(3) Multiple Locations: A separate application is required for each location where the provider intends to operate a residential treatment facility.

(4) Withdrawal of Application: The applicant may withdraw the application at any time during the application process by notifying the Division in writing. At such time, all materials shall be returned to the applicant.

Stat. Auth.: ORS 430.256 Stats. Implemented: ORS 430.010 - 430.030, 430.306, 430.397, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020, 813.260 & 813.500


OAR 415-012-0032 (eff. 5/3/2013) 6

415-012-0032 – Initial Application Information

Initial Application Information: An applicant for a LOA or license shall submit the information listed below on forms provided by the Division:

(1) Name and address of the applicant;

(2) Name, address, and qualifications of the executive director or administrator;

(3) Outline of the staff organization with names and qualifications;

(4) Articles of incorporation and bylaws;

(5) Names and addresses of the board of directors, sponsors, or advisory boards of the program;

(6) Names and addresses of physicians, other professionally trained personnel, medical facilities, and other individuals or organizations with whom the program has a direct referral agreement or is otherwise affiliated;

(7) Description of the treatment services provided by the program setting forth program philosophy, goals, objectives, and a description of the treatment methodology for each service element;

(8) Materials demonstrating compliance with the administrative rules governing the specific service provided;

(9) Materials showing compliance with all related federal, state and local acts, ordinances, rules and amendments such as State Fire Marshal rules, board of health and building zoning codes, and the American Disabilities Act;

(10) Materials substantiating compliance with distance requirements subject to ORS 430.590 for programs using methadone to treat opioid addiction. These application procedures apply to new programs and existing programs moving to a new location after 1-14-2013.

(11) Materials substantiating compliance with other licensing authorities such as the Children, Adults and Families (CAF) Division for residential adolescent services or the Drug Enforcement Administration and a federally approved accreditation agency for methadone treatment services;

(12) For residential treatment and detoxification facilities, the maximum individual capacity requested;

(13) Source of funds used to finance the program such as an annual budget of the organization or a copy of the most current fiscal audit or review;


7 OAR 415-012-0032 (eff. 5/3/2013)

(14) Written evidence of applicable insurance such as liability insurance;

(15) Floor plan for the proposed facility;

(16) Representative sample individual file;

(17) Written nondiscrimination policy including:

(a) Explanation of methods used to disseminate the policy;

(b) Description of procedures used to communicate with sensory impaired person or persons of limited English proficiency;

(c) Written statement about the accessibility of the facility and services for disabled persons; and

(d) Written grievance procedure for handling discrimination complaints.

Stat. Auth.: ORS 413.042 & 430.256

Stats. Implemented: ORS 430.010-30, 430.306, 430.397, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020, 813.260 & 813.500


OAR 410-120-0035 (12/14/2016) 8

415-012-0035 – Responses To Application

(1) Application Satisfactory: If the application is found to be complete and if the material documents compliance with applicable administrative rules, the Division shall issue a license no later than 30 days after final approval of the application.

(2) Unsatisfactory Application: If the application is not complete or if the application does not document compliance:

(a) The applicant shall be provided with written notification that identifies needed information or areas of non-compliance within 60 days of receipt of the application; and

(b) The original application shall be kept on file for 60 days after written notice has been given, at which time, if no further material is submitted to correct the deficiencies noted, the application shall be denied and all material shall be returned to the applicant.

(3) Application Denied: If a license is denied:

(a) The applicant shall be entitled to a hearing with the Chief Officer if the applicant requests a hearing in writing within 60 days of the receipt of the notice;

(b) The Assistant Chief Officer, whose decision is final, shall hold a hearing within 60 days of receipt of the written request; and

(c) If no written request for a hearing is received within the 60-day timeline, the notice of denial shall become the final order by default and the Chief Officer may designate its file as the record for purposes of order by default.

Stat. Auth.: ORS 413.042 & 430.256 Stats. Implemented: ORS 430.010-30, 430.306, 430.397, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020, 813.260 & 813.500


9 OAR 415-012-0040 (12/14/2016)

415-012-0040 – Licenses

(1) The Division may issue a residential license under these rules for a duration not to exceed two years.

(2) Renewal: Renewal of licenses shall be contingent upon demonstration of compliance with appropriate administrative rules:

(a) A program may continue to operate until final determination of its approval or licensure status is made by the Division;

(b) Failure to demonstrate compliance may result in the issuance of a provisional license, suspension, or revocation.

(3) Provisional Certification: Programs with provisional licenses upon demonstrating substantial compliance with appropriate administrative rules may be eligible for a two-year license. However, the provider's failure to demonstrate substantial compliance may result in an extension, suspension, or revocation of the provisional license.

(4) Nondiscrimination; Special Populations: The Division shall not discriminate in its review procedures or services on the basis of race, color, national origin, age, or disability. The Division may issue licenses to specialized programs to assure maximum benefit for special populations, in which case, the Division may identify that special population in the license and impose applicable program criteria.

(5) Restrictions: Restrictions which may be attached to a license include:

(a) Limiting the total number of individuals (in residential or detoxification treatment);

(b) Defining the age level of individuals (i.e., youth or adult) to be admitted into the facility;

(c) Defining the gender of individuals, if the provider is identified as serving only males or females;

(d) Assuring compliance with other licensing entities such as the CAF Division, the State Public Health Division, or the Food and Drug Administration; or

(e) Other restrictions as required by the Division.

(6) Time Limits on Restrictions: Restrictions may be imposed for the extent of the approval period or limited to some other shorter period of time. If the restriction corresponds to the licensing period, the reasons for the restriction shall be considered at the time of renewal to determine if the restrictions are still appropriate.


OAR 415-012-0040 (12/14/16) 10

(7) Restriction to Appear on License: The effective date and expiration date of the restriction shall be indicated on the certificate.

(8) Non-Transferability: A license issued by the Division for the operation of a residential substance use disorder program applies both to the applicant program and the premises upon which the program is to be operated. A license is not transferable to another person, entity, or to any other location:

(a) Any person or other legal entity acquiring an approved licensed facility for the purpose of operating a substance use disorder program shall make an application as provided herein for a new LOA or license;

(b) Any person or legal entity having been issued a license and desiring to fundamentally alter the treatment philosophy or transfer to different premises must notify the Division 30 days prior to doing so in order for the Division to review the program or site change and to determine further necessary action.

(9) Change of Administrator: If the administrator of the program changes during the period covered by the license:

(a) A request for a change must be submitted to the Division within 15 days, along with the qualifications of the proposed new administrator;

(b) Upon a determination that the administrator meets the requirements of applicable administrative rules, a revised license shall be issued with the name of the new administrator.

(10) Discontinued Program: When a program is discontinued, its current license is void immediately and the certificate shall be returned to the Division. A discontinued program is one which has terminated its services for which it has been approved or licensed. A program planning to discontinue services must:

(a) Notify the Division 60 days prior to a voluntary closure of a facility with written notice of how the provider will comply with OAR 309-014-0035(4) and 42 CFR Part 2, Federal Confidentiality Regulations, regarding the preservation of all individual records; and

(b) Provide individuals 30 days written notice and shall be responsible for making reasonable efforts to obtain treatment placement of individuals as appropriate.

Stat. Auth.: ORS 430.256 Stats. Implemented: ORS 430.397, 430.010-030, 430.306, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020, 813.260 & 813.500


11 OAR 410-012-0050 (12/14/2016)

415-012-0050 – Onsite Reviews and Access Requirements

(1) Scheduled Inspections: The Division shall inspect the facilities and must review procedures utilized:

(a) Before issuing a LOA or license to an applicant; and

(b) Before renewal of an existing LOA or license.

(2) Discretionary Onsite Inspections: The Division may conduct onsite inspections:

(a) Upon receipt of verbal or written complaints of violations that allege conditions that may threaten the health, safety, or welfare of individuals or for any other reason to be concerned for individual welfare; or

(b) Any time the Division has reason to believe it is necessary to assure if a provider is in compliance with the administrative rules or with conditions placed upon the license.

(3) Substance of Reviews: The review may include but is not limited to case record audits and interviews with staff and individuals, consistent with the confidentiality safeguards of state and federal laws.

(4) Access to Facilities and Records: Each applicant or provider agrees, as a condition of license approval:

(a) To permit designated representatives of the Division to inspect premises of programs to verify information contained in the application or to assure compliance with all laws, rules, and regulations during all hours of operation of the facility and at any other reasonable hour;

(b) To permit properly designated representatives of the department to audit and collect statistical data from all records maintained by the approved or licensed program; and

(c) That such right of immediate entry and inspection shall, under due process of law, extend to any premises on which the Division has reasons to believe a program is being operated by the provider in violation of these rules.

(5) Access if Requirement for License: An applicant or provider shall not be granted licensing which does not permit inspection by the Division or examination of all records, including financial records as appropriate, methods of administration, the disbursement of drugs and method of supply, and any other records the Division considers to be relevant to the establishment of such a program.


OAR 415-012-0050 (12/14/2016) 12

(6) Inspection by Other Agencies: Each applicant or provider agrees, as a condition of license approval that:

(a) State or local fire inspectors shall be permitted access to enter and inspect the facility regarding fire safety upon the request of the Division; and

(b) State or local health inspectors shall be permitted access to enter and inspect the facility regarding health safety upon the request of the Division.

(7) Notice: The Division has authority to conduct inspections with or without advance notice to the administrator, staff, or individuals:

(a) The Division is not required to give advance notice of any onsite inspection if the Division reasonably believes that notice might obstruct or seriously diminish the effectiveness of the inspection or enforcement of these administrative rules; and

(b) If Division staff are not permitted access for inspection, a search warrant may be sought.



13 OAR 415-012-0055 (12/14/2016)

415-012-0055 –Review Process and Review Reports

(1) For renewal of a license: The Division shall designate a lead specialist and other onsite review members as appropriate to perform a formal onsite review of the service element or elements;

(2) Access to Reports: Public access to final reports of onsite inspections, except for confidential information, shall be available upon written request from the Division during business hours in accordance with OAR chapter 407, division 003.

(3) Corrective Action Plan. Programs issued a provisional license must submit an action plan to the Chief Officer or his or her designee for approval no later than 30 days following receipt of the final onsite report. The corrective action plan shall include, but not be limited to:

(a) Specific problem areas cited as out of compliance;

(b) A delineation of corrective measures to be taken by the program to bring the program into compliance; and

(c) A delineation of target dates for completion of corrective measures for each problem area.

(4) Failure to Take Corrective Action: Failure to demonstrate compliance with the corrective action plan may result in an extension, suspension or revocation of the provisional license.

Stat. Auth.: ORS 413.042 & 430.256 Stats. Implemented: ORS 430.01030, 430.306, 430.397, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020, 813.260 & 813.500


OAR 415-012-0057 (6/19/2014) 14

415-012-0057 – Organizational Provider Assessment Information

In addition to the review procedures outlined in Section 415-012-0055, the Division will ensure that the following minimum information will be obtained during the site reviews;

(1) A current program description that reflects the type and scope of behavioral health services provided by the applicant;

(2) Provider policies regarding credentialing practices of individual practitioners. The policies must reflect current credentialing standards as defined by nationally accepted accrediting bodies such as The Joint Commission, the National Committee for Quality Assurance, and/or URAC;

(3) Copies of the provider’s liability insurance coverage;

(4) Copies of the provider’s policies and procedures regarding seclusion and restraint practices; and

(5) Copies of the provider’s Code of Conduct.

Stat. Auth.: ORS 413.042 & 430.256

Stats. Implemented: ORS 430.01030, 430.306, 430.397, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020, 813.260 & 813.500


15 OAR 415-012-0058 (6/19/2014)

415-012-0058 – Availability of Information to Coordinated Care Organizations and Other Health Plans

Upon completion of the site review process and the issuance of a Certificate of Approval for Mental Health Services, the Division shall make copies of the following information available to Coordinated Care Organizations and other health plans for the purpose of credentialing a provider:

(1) A current program description that reflects the type and scope of behavioral health services provided by the applicant;

(2) Provider policies and procedures regarding the provider’s credentialing practices of individual clinicians;

(3) Statements of provider’s liability insurance coverage;

(4) An attestation from the Authority verifying that the provider has passed a screening and meets the minimum requirements to Medicaid provider;

(5) Reports detailing the findings of the Division’s site review of the provider;

(6) The provider’s Medicaid Vendor Identification Number issued by the Authority;

(7) Copies of the provider’s policies and procedures regarding seclusion and restraint practices; and

(8) Copies of the provider’s Code of Conduct.

Stat. Auth.: ORS 413.042 & 430.256

Stats. Implemented: ORS 430.01030, 430.306, 430.397, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020, 813.260 & 813.500


OAR 415-012-0060 (12/14/2016) 16

415-012-0060 – Denial, Revocation, or Non-renewal

(1) Denial of Application or Request for Renewal: The Division shall deny an application or request for renewal, or revoke alicense where it finds any of the following:

(a) The provider has substantially failed to comply with applicable administrative rules or with local codes and ordinances or any other applicable state or federal law or rule;

(b) The applicant or provider has had a prior LOA or license to operate an alcohol and drug use disorder treatment program denied, revoked, or refused to be renewed in any county in Oregon within three years preceding the present application for reason of abuse or neglect of individuals or the administrator's failure to possess adequate physical health, mental health, or good personal character;

(c) If such prior denial, revocation, or refusal to renew occurred more than three years from the present action, the provider is required to establish to the Division by clear and convincing evidence his or her ability and fitness to operate a treatment program. If the applicant or provider does not provide such evidence, the Division shall deny the application;

(d) The applicant or provider submits fraudulent or untrue information to the Division;

(e) The applicant or provider has a history of, or currently demonstrates, financial insolvency such as filing for bankruptcy, foreclosures, eviction due to failure to a pay rent, termination of utility services due to failure to pay bills, failure to pay taxes such as employment or social security in a timely manner;

(f) The applicant or provider refuses to allow immediate access and onsite inspection by the Division; or

(g) The applicant or provider fails to maintain sufficient staffing or fails to comply with staff qualifications requirements.

(2) Notification of Denial: When the Division determines that an applicant's request for a license should be denied, the Chief Officer or designee shall notify the applicant, by certified mail, return receipt requested, of the Division's decision to deny the licensure and the reasons for the denial.



17 OAR 415-012-0065 (12/14/2016)

415-012-0065 – Suspension of License

If the Division finds that the health, safety, or welfare of the public are seriously endangered by continued operation of a treatment or prevention program and sets forth specific reasons for its findings, summary suspension of a license may be ordered. The Division may suspend a license for any of the following reasons:

(1) Violation by the program, its director or staff, of any rule promulgated by this Division pertaining to treatment or prevention services;

(2) Permitting, aiding or abetting the commitment of an unlawful act within the facilities maintained by the program, or permitting, aiding or abetting the commitment of an unlawful act involving chemical substances within the program;

(3) Conduct or practices found by the Division to be detrimental to the general health or welfare of an individual in the program; or

(4) Deviation by the program from the plan of operation originally approved or licensed which, in the judgment of the Division, adversely affects the character, quality or scope of services intended to be provided to individuals within the program.



OAR 415-012-0067 (12/14/2016) 18

415-012-0067 – Response to Criminal Records

(1) The Division may deny, refuse to renew, suspend, or revoke a license if:

(a) Any of the program's staff, within the previous three years, has been convicted of:

(A) Any crime or violation under ORS chapter 475, including but not limited to the Uniform Controlled Substances Act, or under ORS 813.010, driving under the influence of intoxicants;

(B) A substantially similar crime or violation in any other state; or

(C) Any felony.

(b) Any of the program's staff has entered into, within the past three years, a diversion agreement under ORS 813.010 or 135.907 through 135.921, or a diversion agreement under a substantially similar law in any other state;

(2) Criminal Record Checks: The Chief Officer or designee may make criminal record inquiries necessary to ensure implementation of these rules.



19 OAR 415-012-0070 (7/1/2016 (T))

415-012-0070 – Hearings (T)

(1) Requesting Hearings: If a license is suspended, not renewed, or revoked: The provider shall be entitled to a hearing preceding the effective date of the denial, suspension, non-renewal, or revocation if requested in writing within 21 days after receipt of notice. If no timely written request is received, the notice shall become the final order by default and the Chief Officer may designate the Division file as the record for purposes of order by default.

(2) Contested Case Hearings: Programs that wish to contest the suspension, non-renewal, or revocation of their license shall have an opportunity for a hearing by the Division according to the Attorney General's Model Rules of Procedure.


Stats. Implemented: ORS 430.397, 430.010-030, 430.306, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020, 813.260 & 813.500


OAR 415-012-0080 (12/14/2016) 20

415-012-0080 – Complaints

(1) Investigation of Complaints: Any person who believes that administrative rules have been violated may file a complaint with the Division:

(a) The Division may require that complainant exhaust grievance procedures available to them through the provider prior to initiation of an investigation;

(b) The Division shall investigate complaints and notify the provider of the results of the investigation and any proposed action.

(2) Records of Complaints: A record shall be maintained by the Division of all complaints and any action taken on the complaint and shall:

(a) Be placed into the public file. Any information regarding the investigation of the complaint shall not be filed in the public file until the investigation has been completed;

(b) Protect the identification of the complainant; and

(c) Treat the identities of the witnesses and individuals as confidential information.

(3) Inspection of Records: Any person may inspect and receive a photocopy of the public complaint files maintained by the Division upon requesting an appointment to do so. A fee shall be charged in accordance with OAR chapter 407, division 003.

(4) Substantiated Complaint Grounds for Action: Providers who acquire substantiated complaints pertaining to the health, safety, or welfare of individuals may have their LOA or licenses suspended, revoked, or not renewed and arrangements made to move the individuals.

(5) Retaliation Toward An Individual Forbidden: The provider shall not retaliate against any individual for filing a complaint with the Division by:

(a) Increasing charges; decreasing services; rights or privileges;

(b) Threatening to increase charges or decrease services, rights, or privileges;

(c) Taking or threatening to take any action to coerce or compel the individual to leave the facility; or

(d) Abusing or threatening to harass or abuse an individual in any manner.

(6) Retaliation Toward Employee or Witness: The provider shall not retaliate against any complainant, witness, or employee of a facility for making a report to or being


21 OAR 415-012-0080 (eff. 5/3/2013)

interviewed by the Division about a complaint including restriction to access to the service or to an individual or, if an employee, to dismissal or harassment.


Stats. Implemented: ORS 430.397, 430.010-030, 430.306, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020, 813.260 & 813.500


OAR 415-012-0090 (12/14/2016) 22

415-012-0090 – Variance or Exception

(1) Procedure for Submission of Request. Request must be made in writing:

(a) For an initial application it should be included with the application documents;

(b) If the provider is an agency under contract with the local mental health authority, it must submit the request through the local mental health authority to the Chief Officer; and

(c) If the provider is not under contract to the local mental health authority, the request should be submitted directly to the Chief Officer.

(2) Substance of Request: The request should include the following:

(a) The reason for the proposed variance or exception;

(b) The alternative practice proposed; and

(c) For an exception, a plan and timetable for compliance with the section of the rule from which the exception is sought.

(3) Approval or Denial: The Chief Officer, whose decision shall be final, shall approve or deny the request for variance or exception.

(4) Notification: The Division shall notify the provider requesting the variance or exception and the community mental health program of the decision.

(5) Variance Part of License: A variance granted by the Division shall be attached to, and become part of, the LOA or license. Continuance of the variance shall be reviewed at the time the license is considered for renewal.

Stat. Auth.: ORS 430.256 Stats. Implemented: ORS 430.010-030, 430.306, 430.397, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020, 813.260 & 813.500

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